Recibido: 11-07-2020Aceptado: 02-12-2020

Correspondencia: Mathias Orellanamiorellanadonoso@gmail.com

Orellana M, Valenzuela J, Díaz M, Gold M, Rubio J. Effectiveness and current recommendation of manual therapy on hip osteoarthritis. An overview. Rev Soc Esp Dolor. 2020;27(6):375-391

Effectiveness and current recommendation of manual therapy on hip osteoarthritis. An overviewEfectividad y recomendación de la terapia manual sobre la artrosis de cadera. Revisión panorámicaM. Orellana1, J. Valenzuela2,3, M. Díaz3, M. Gold3 y J. Rubio4

1Departamento de Ciencias Morfológicas. Facultad de Medicina y Ciencia. Universidad San Sebastian. Santiago, Chile. 2Facultad de Ciencias de la Salud. Universidad de las Américas. Santiago, Chile. 3Universidad Andrés Bello. Departamento de Morfología, Facultad de Medicina. Santiago, Chile. 4Emergencias. Hospital Sótero del Río. Puente Alto, Santiago, Chile

ABSTRACT Introduction: Osteoarthritis (OA) is the most common

joint disease, increases with age and it is estimated that in those over 60 years of age more than 80 % have OA in at least one joint. Currently, the evidence regarding manual therapy (MT) in hip OA has had unclear results. Therefore, the main objective of this study is to deter-mine the effectiveness and recommendation of MT in the hip OA. And secondary objectives, (I) review the existing literature on the intervention of MT in hip OA, (II) calculate the effectiveness of MT techniques in hip OA and (III) determine if there are benefits after the MT intervention in hip OA.

Methods: A systematic search was carried out in electronic databases, in order to compile the available literature between the years 2000 and 2019, taking as reference the PRISMA statement for systematic reviews. Letters to the editor, bibliographic reviews and gray literature were excluded.

Results: After reviewing 30 articles, we included 7 RS and 14 RCTs. 7 RCTs measured pain intensity of OA in response to MT vs. a control group. 4 RCTs measuring pain intensity in hip OA using MT + exercises Seven RCTs measured function in subjects with hip OA in response to MT vs. CG. Two RCTs evaluated the effects of MT + Ex on function.

Discussion: Although the results were in favor of manual therapy, compared to the control group, these

RESUMEN Introducción: La osteoartritis (OA) es la enferme-

dad articular más frecuente, aumenta con la edad y se estima que en los mayores de 60 años más del 80 % tienen OA en, al menos, una articulación. Actualmente, la evidencia respecto a la terapia manual (TM) en la OA de cadera ha tenido resultados poco claros, por lo que el objetivo principal de este estudio es determinar la efectividad y recomendación de TM en la OA cadera. Los objetivos secundarios son: a) revisar la literatura existente sobre la intervención de TM en OA de cadera; b) calcular la efectividad de las técnicas de TM en OA de cadera, y c) determinar si hay beneficios después de la intervención de TM en OA cadera.

Métodos: Se realizó una búsqueda sistemática en bases de datos electrónicas, con el fin de recopilar la literatura disponible entre los años 2000 y 2019, tomando como referencia la declaración PRISMA para revisiones sistemáticas. Se excluyeron las cartas al edi-tor, revisiones bibliográficas y literatura gris.

Resultados: Después de revisar 30 artículos, inclui-mos 7 RS y 14 ECA. 7 ECA midieron la intensidad del dolor de la OA en respuesta a TM vs. un grupo de control. 4 ECA que midieron la intensidad del dolor en la OA de cadera que usaban TM + ejercicios Siete ECA midieron la función en sujetos con OA de cadera en respuesta a TM vs. CG. Dos ECA evaluaron los efectos de TM + Ex en la función.

REVISIÓN DOI: 10.20986/resed.2020.3835/2020

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DEFINITION OF OSTEOARTHROSIS

Osteoarthritis (OA) was classically defined as a degen-erative joint condition characterized by progressive loss of articular cartilage, marginal bone hypertrophy (osteophytes), and changes in the synovial membrane, however today it is recognized that in this disease there is a protein and gene pattern of inflammatory charac-teristics similar to that found in diseases as diverse as rheumatoid arthritis or metabolic syndrome, for which reason the inflammatory component is currently rec-ognized as a fundamental part (1). The Osteoarthritis Research Society International (OARSI) unifies concepts worldwide and defines OA as a disorder involving mobile joints characterized by cellular stress and degradation of the extracellular matrix initiated by micro and mac-ro lesions that activate maladaptive repair responses, including proinflammatory pathways of innate immunity. The disease manifests itself first as a molecular disor-der (abnormal metabolism of joint tissue) followed by anatomical and/or physiological disorders (character-ized by cartilage degradation, bone remodeling, osteo-phyte formation, joint inflammation, and loss of normal joint function) that can culminate in illness (2). Howev-er, OARSI considers the need to develop a permanent process of standardized definitions of OA, thus helping to advance the development of drugs and research to promote understanding and treatment of this disease. That is why these definitions would be subject to regular refinement as new scientific advances demand it (3).

EPIDEMIOLOGY, PREVALENCE AND INCIDENCE OF HIP OA

Osteoarthritis (OA) remains a globally important public health problem, as described in OARSI’s recent technical report, Osteoarthritis: Research Society. As noted in the document, OA affects 240 million people worldwide, about 10 % of men and 18 % of women over the age of 60 (4). More than 80 % of those over 55 are Radiological OA, but only 10 to 20 % manifested some limitation of their activities due to OA. Among the symptomatic OA in peripheral joints, only 6 % have monoarticular symptoms, the rest are polyarticular. The frequency of involvement of the var-

ious joint groups are: knee 41 %, hands 30 %, hip 19 % (5). The prevalence of OA increases over time, being almost permanent in senescents aged 75 years or older. This condition is one of the main causes of physical disability in adults, affecting their financial sit-uation and lifestyle. Increased life expectancy and an aging world population are projected to make OA the fourth leading cause of disability in 2020. Global data is sparse. In hip OA, values of 47 to 88 cases per 100,000 inhabitants have been reported, while inci-dences between 164 and 240/100,000 have been estimated for the knee (6).

The first estimates in the Spanish population, using clinical criteria for diagnosis, estimated the prevalence of OA in the urban population at 23.8 %, with a 2:1 female:male ratio. Authors point out that the appear-ance of hip OA is associated with personal factors, such as advanced age, ethnicity, comorbidities, den-sity and considerable bone mass, and heredity. While there are joint factors such as polyarthrosis, carrying heavy loads, bone morphology and joint alignment. At the national level, according to data from the Nation-al Health Survey carried out in 2003, 3.8 % of the adult population reported suffering from osteoarthritis (self-report), the highest frequency among women and the highest in the measure that age increases (7).

PATHOPHYSIOLOGY

Osteoarthritis (OA) is characterized by the degener-ation of the hyaline cartilage of the joints and is asso-ciated with the aging of the organism. One of the main characteristics is the slowness of its progression, which implies that the detection of loss of joint integrity is after years of evolution. The development of this patholo-gy affects not only cartilage, but also the subchondral bone, joint capsule and peri-articular soft tissues, where in its final phase there is evidence of cartilage repair failure leading to degradation of the extracellular matrix (ECM), death of chondrocytes and total loss of cartilage integrity (8). The synovial membrane in the final stages of OA is said to develop an inflammatory response that contributes to the way pathology is expressed clinically, thus a patient with a severe OA condition closely resem-bles clinical expression from a patient with rheumatoid

Discusión: Si bien los resultados estuvieron a favor de la terapia manual, en comparación con el grupo control estos no fueron estadísticamente significativos, por lo cual proponemos realizar nuevos estudios prima-rios para eliminar algunos sesgos en la ejecución del programa y mejorar la intervención en ambos grupos.

Palabras clave: Artrosis de cadera, terapia manual, terapia para artrosis, terapia multicomponente.

were not statistically significant, so we propose to car-ry out new primary studies to eliminate some biases in program execution and improve intervention in both groups.

Key words: Hip osteoarthritis, manual therapy, thera-pies osteoarthritis, multicomponent therapies.

EFFECTIVENESS AND CURRENT RECOMMENDATION OF MANUAL THERAPY ON HIP OSTEOARTHRITIS. AN OVERVIEW 377

arthritis (RA), since similar changes are observed in the synovial membrane (9). OA has not been considered as an inflammatory arthropathy because they have not been found or there is a shortage of neutrophils in the synovial fluid, because it has the characteristic that the articular cartilage is avascular, it has no lymphatic drainage or innervation, so it is not possible to demon-strate the systemic manifestations of an inflammatory process as such, which prevents compliance with the classic signs of inflammation, however there are stud-ies that demonstrate the existence of pro-inflammatory mediators such as cytosines (Interleukin - 1b and 6) and alfa Tumor Necrosis Factor (FNTalfa) which may be relevant in the development of OA (10).

The most common theory that attempts to explain the failure of cartilage is the loss of balance between anabolism and catabolism of the chondrocyte, which causes an imbalance between the synthesis and degra-dation of the extracellular matrix of articular cartilage. This leads to an accelerated destruction of the extra-cellular matrix (ECM) where the proteolytic enzymes of the chondrocytes themselves and synovial cells appear as those responsible, in addition there is an alteration in the cartilage repair systems (11). Proteoglycans are the majority component in the ECM, and are the first to be affected in OA, decreasing their concentration as the disease progresses. On the other hand, chon-drocytes are not able to compensate for proteoglycan deficiency which results in a net reduction of the extra-cellular matrix. In earlier stages when the rupture of the surface layer occurs, small fragments of proteogly-cans are released that come from the degradation of the same matrix to the synovial fluid, which stimulates the synthesis of IL-1b, IL-6 and TNF-a, among others pro-inflammatory mediators that act on cartilage inhib-iting the synthesis of proteoglycans, further stimulating its degradation, which leads to a vicious feedback loop that perpetuates more and more inflammation of the membrane, causing irreversible fibrillation of articular cartilage (12). There are also hypotheses that suggest that the origin of OA is a consequence of a systemic disorder affecting the differentiation of stromal cells and lipid metabolism. This based on the fact that there is a close relationship between OA and obesity due to the common mesenchematic origin of the cells of the tissues that form the articular cavity, and the possible role of neuroendocrine mediators (such as leptin) in the regulation of mass (13). The chondrocyte plays a fun-damental role in maintaining the integrity of the ECM of the articular cartilage, as well as in repairing the dam-age that the cartilage may suffer. OA is characterized by a change in the number of cells, which depends on the balance between cell birth (mitosis) and cell death. Cell death in its two forms, apoptosis and necrosis, is believed to be relevant in cartilage cell homeostasis. The difference between these two types of cell death is that apoptosis (cell suicide) does not trigger an inflam-matory response since it is an active process that is under molecular control that also requires energy con-sumption. This energy is used to generate a disorder of the cellular structures, thus avoiding tissue damage, therefore, there is no inflammatory process (14). Stud-ies show that nitric oxide (NO) plays a fundamental role in OA pathology, since its effect has been demonstrated

in the inhibition of chondrocyte proliferation and in turn induces apoptosis in articular chondrocytes in humans. On the other hand, there are data that also show that the mitochondria suffer alterations in their respiratory chain (in an arthrosic chondrocyte) where they could also intervene in the apoptosis of the chondrocyte. Other studies mention that NO and some eicosanoids are involved in joint cartilage damage, specifically pros-taglandin E2 (PGE-2) that affects remodeling, has a direct inflammatory action, may potentiate the effect of other proinflammatory mediators and the production of metalproteases. As well as leukotriene B4 (LT-B4) it also stimulates the release of cytosines such as IL-1b and TNF-alfa (15). Some studies mention that there is an increase in resorption at the beginning of the dis-ease in patients with OA, which contributes to the loss of subchondral bone and also stimulates the production of some proteases such as cathepsin K and metalprote-ase. Bone to compensate for damage caused by bone resorption responds with the production of “new bone” and marginal osteophytes are the result of manifesting as nodules that can become inflamed or can irritate neighboring structures (16). Caspases are proteolytic enzymes that are activated in cellular apoptosis, these are divided according to their function; caspases that are involved with cytokine maturation (caspases 1, 4, and 5); effector caspases (caspases 3, 6 and 7) and initiator caspases (caspases 8, 9 and 10). The caspase cascade is believed to play an important role in the mechanism by which NO mediates apoptosis in chon-drocytes. Together with NO, interleukin-1B (IL-1B) and tumor necrosis factor-alpha (TNF-alpha) induce modula-tion and expression of caspases in normal and arthritic chondrocytes (17). Other proteins involved in apoptosis are from the family of cell death proteins such as Bcl-2, which have implications for the survival of chondrocytes in OA. Finally, Fas ligation (LFas) is a cytokine respon-sible for regulating apoptosis since they are found in articular chondrocytes, which means that when this system is activated they contribute to apoptosis of the chondrocyte. It is in the superficial region of cartilage in OA where the greatest number of apoptotic cells are located and where Fas is expressed in chondrocytes, which bind to LFas, and induce chondrocyte apoptosis, however, at the level of the arthrosic synovial fluid, the concentration of LFas is very low. Chondrocytes have the ability to produce varieties of inflammation media-tors, in turn the control of cartilage matrix deposition is not only related to the production of components of the ECM such as proteoglycans (PG) and type II collagen, As previously discussed, it is related to the balance between production and degradation. The function of the chondrocyte must be differentiated under normal and pathological conditions. First, under normal con-ditions, we know that its function is to maintain the balance between the substances it produces, but under pathological conditions, the chondrocyte responds to different stimuli, producing mediators of inflammation and enzymes that go to alter your normal metabolism. The proteolytic enzymes responsible for generating irreversible changes in normal joint architecture are Metalproteases (MMP). The activity that these enzymes develop is controlled by specific inhibitors (MMP tissue inhibitors) where 3 different forms are identified in the

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tissues of the human joint. TIMP-1, TIMP-2 and TIMP-3 which are present in cartilage and are synthesized under OA conditions by chondrocytes. There is an imbal-ance between the concentration of MMP and TIMP in the osteoarthritic cartilage and a relative difference of the TIMP is generated, this same condition has been found in the synovial fluid of OA (18).

Within the MMP families, stromelysins (MMP-3, MMP-10) and gelatinases (MMP-2, MMP-9) are those that generate greater severity in arthrosic cartilage and it has been shown that MMP-values 3 are extremely high compared to other MMPs in the synovial fluid of OA patients. Stromelysins have great capacity to degrade multiple components of the ECM, however, they can also activate inactive forms of other MMPs, therefore, they have a leading role in the destruction and progres-sion of the cartilage matrix (19). There are 3 areas by which the articular cartilage is organized, these areas are the superficial, middle and deep and the cell den-sity decreases from the superficial to the deep area. Half or one third of the cells in the superficial zone are represented in the deep zone, and adjacent to the deep zone is a calcified zone that is formed as a result of endochondral ossification. Of the 3 zones the one that is exposed to different tension, shear and compression forces is the superficial zone. This zone is made up of collagen fibers that provide it with greater strength to resist the different forces it is subjected to, and also flattened cells that are located parallel to each other in the superficial layer of cartilage. It is worth mentioning in a very important way that the calcified area is isolat-ed from the most superficial layers, so the low repair capacity is a product of the low irrigation of the most superficial tissue. There are two conditions by which the OA is developed; first when the biostructural prop-erties of cartilage and subchondral bone are normal, but there is an excess of articular load which leads to tissue changes; second when the load is normal but the biostructural structures are deficient (20).

CLINICAL PRESENTATION OF HIP OA

OA is very likely to have a long asymptomatic period and is therefore difficult to detect in the early stages. Patients come for consultation when pain appears with progressive functional limitation, constituting a common reason for medical consultation and a frequent cause of deterioration in lifestyle. There are studies that show that up to 50% of people with symptomatic OA suffer some degree of disability (21).

The main clinical manifestations associated with OA are: joint pain, stiffness after inactivity, mainly pain. Joint pain in OA is relieved by rest but increases with resump-tion of activity. Osteoarthritic knee pain is typical, which is exaggerated when starting to walk after rest and is relieved after walking a little. Locations lead to different clinical pictures (9). In the hands, in addition to pain, Heberden and Bouchard nodules may appear, in the dis-tal and proximal interphalangeal joints, respectively, or rhizarthrosis when it is in the metacarpophalangeal joint of the thumbs. Knee OA is a typical case of disability. In addition to pain and inflammation, crepitus and muscle atrophy may appear. Hip OA is characterized by pain local-

ized to the hip itself or radiating to the thigh and knee. In the spine it can appear in the cervical, dorsal and lumbo-sacral segments, affecting the intervertebral discs, the vertebral bodies and the apophyseal joints (22).

The diagnosis of OA is essentially clinical. Radiological findings can also be very useful in evaluating anatomical changes, possible complications, and the degree of dis-ease progression, but they do not always correlate with the degree of symptomatology or joint dysfunction. In general, the radiological signs in all osteoarthritis are: narrowing of the joint space, presence of subchondral sclerosis, subluxation, cysts and osteophytes (23).

Bone scintigraphy (Nuclear Magnetic Resonance) is recommended when considering an osteotomy and requiring knowledge of the actual situation of the joint’s external behavior. Arthroscopy is a technique that allows a more detailed description of the depth and extent of the lesion, as well as the very early detection of softening and fibrillation (24).

TREATMENT OF HIP OA

Currently, there is no treatment that reverses and heals OA, only therapies are available whose therapeu-tic objective is to control and improve symptoms such as pain, functionality and delayed disease progression. In this sense, considering the available clinical evidence, the European League Against Rheumatism (LECR) and the International Society for Osteoarthritis Research (SIIOA), developed a series of recommendations to combat OA, mainly based on using pharmacological and non-pharmacological measures, being individual-ized with the characteristics of each patient, the joint involved, the clinical involvement and the existence of other underlying pathologies (25).

PHARMACOTHERAPY

Among the drugs most commonly used to counteract the symptoms of OA are non-steroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase enzyme inhibitors (COX), which, although they do not prevent cartilage damage, help to relieve pain and inflammation. Nonspe-cific NSAIDs (aspirin, diclofenac, ibuprofen, indometh-acin, piroxicam, among others), non-specifically inhibit COX-1 and 2 with greater effect on the former, how-ever they produce various adverse events (AE), among which stand out gastrointestinal symptoms induced by COX-1 inhibition leading to reduced synthesis of prosta-glandins (gastroprotective factors of the gastric muco-sa), increased blood flow to the gastric mucosa, and increased acid secretions and oxidative stress (OS). The introduction of COX-2 inhibitors was intended to produce similar effects with a reduction in gastrointestinal AEs, however, there is evidence that these agents increase cardiovascular risk, a frequent condition in older patients that is most sensitive to OA and receiving treatment with NSAIDs, therefore, its use has been limited, even being contraindicated by the European Medicines Agency in patients with ischemic heart disease or stroke, so they should be used with caution in cases of hypertension, hyperlipidemia, diabetes and in smokers (26).

EFFECTIVENESS AND CURRENT RECOMMENDATION OF MANUAL THERAPY ON HIP OSTEOARTHRITIS. AN OVERVIEW 379

For their part, COX-3 inhibitors, such as acetamin-ophen, do not present these risks, making it the oral analgesic of first choice, however its anti-inflammatory effect is low, and higher doses can be associated (> 10 g/d) at the risk of liver complications and increase the effect of anticoagulants.

Regarding the topical use of NSAIDs, it allows reduc-ing AE and minimizing systemic toxicity, but according to a meta-analysis it is not effective in the long-term treatment of this pathology (27).

Considering all the above aspects, paracetamol is the first pharmacological option suggested in the OA management guides of the European League against Rheumatism, as well as the American College of Rheu-matology, while the International Society for Research in Osteoarthritis (ISROA) recommends the use with caution in the case of hypertension, hyperlipidemia, diabetes and in smokers for both COX-2 inhibitors and the rest of NSAIDs. It is worth mentioning that the pre-scription of NSAIDs must be carried out in a person-alized way for each patient, taking into account the characteristics, preferences and cardiovascular and gastrointestinal risk factors of each individual, as well as the overall safety profiles of each medication (28).

On the other hand, opioid treatment is recommend-ed in patients who are not candidates for surgery, as an alternative to NSAIDs, when they are unable to control pain, or have contraindications or intolerance (25-29). In Chile, 2 opioid analgesics are used that can be used orally: codeine and tramadol, indicated as monothera-py or in combination with paracetamol, the risk-benefit evaluation being important in these cases, considering the potential risk of dependency. On the other hand, transdermal fentanyl and buprenorphine have a good safety / efficacy profile if they are correctly prescribed for the treatment of chronic pain (30).

NON-PHARMACOLOGICAL TREATMENT

This type of treatment includes the education of the patient and his family, an exercise program, among others. The delivery of information and education is an essential component of the management of physi-cal therapy, being an obligation of medical teams, as well as a shared responsibility with patients. This is particularly important in chronic diseases such as OA and should include aspects related to the importance of the disease, its forms of study, therapeutic alterna-tives, and prognosis. In this sense, individual or group educational programs, periodic telephone calls and training in techniques to cope with the problem are useful, with an effect size that ranges between 0.28 and 0.35 (31).

In the case of hip OA, an RCT of patients expecting hip joint replacement showed that patients receiving group education had less pain than the control group. The fundamental objective of health education is to pro-mote a better understanding of OA and to promote self-management strategies for this degenerative dis-ease (32). Inclusion in weight reduction programs can help, with dietary recommendations and stretching and aerobics (walking, cycling) to increase strength and muscular endurance, aiding weight loss (33).

Current clinical guidelines recommend exercise ther-apy in the treatment of hip OA, incorporating exercises such as hip stretching, strengthening exercises, and balance tasks. Although OA is a progressive and degen-erative disease that can naturally worsen over time regardless of intervention, the best available evidence seems to favor exercise therapy for short-term pain relief, requiring more RCTs to confirm the duration of the effect. In addition, these exercise programs must be personalized and should be introduced gradually as the patient is able to tolerate it (34).

On the other hand, the use of canes that promote the reduction of joint overload, or footwear with a rub-ber sole and heel or other external devices, that modify the functional or structural aspects of the musculoskel-etal system (insoles, external wedges, knee pads, etc.) may decrease the forces applied to the joint (35).

As for the cold, ice massages can relieve pain in the OA, improving flexion and functionality; while the applica-tion of heat relaxes the muscles, decreases the sensation of pain and improves morning joint stiffness. The use of transcutaneous electrical stimulation can control pain in patients with osteoarthritis of the hip who are not can-didates for pharmacological treatment, with a minimum application of 4 weeks being recommended. Other ther-apies such as electrical muscle stimulation, ultrasound, short wave, laser and magnet therapy have been tested, without sufficient evidence on their efficacy (36).

MANUAL THERAPY IN THE HIP OA

Manual therapy is a physical treatment used by phys-ical therapists, chiropractors, osteopaths, and other practitioners to treat musculoskeletal pain and disability, which includes massage therapy, joint mobilization, and manipulation. Recently published clinical guidelines on the treatment of OA recommend manual therapy as an adjunct treatment (NICE, 2008; RACGP, 2009), howev-er this recommendation was based on a single study.

And it is that in several studies and reviews it can be observed that there is no clear description of what constitutes manual therapy, evidenced in the different criteria they use for the inclusion of studies. That is why some authors use a broad definition of manual therapy.

Regarding the effects of the techniques on pain, Sky-ba et al. showed that they have a role in activating the cortical inhibitory pain system in addition to the release of endorphin, the increase in blood flow that can release local pain mediators. and also psychological influences through the interaction between the doctor and the patient (37).

METHODS

Eligibility criteria

The criteria established by the authors of this panoram-ic review were; systematic reviews published between 2000 and 2017, reviews in spanish or english language, reviews comparing manual therapy intervention as treatment of hip osteoarthritis compared to some oth-er non-surgical treatment modality, which reviews have

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included RCTs with an established and declared random-ization, that the reviews have included patients older than 18 years and with an imaging diagnosis of hip OA.

Electronic search

This panoramic review or Overview considers system-atic reviews with or without meta-analyzes, written in Spanish or English, published between the years 2000 and 2019. A systematic search was carried out in elec-tronic databases, in order to compile the available liter-ature on the subject to be treated, taking as reference the PRISMA statement for systematic reviews (38). The search process was carried out in the following databas-es; MEDLINE, SCIELO, SPORT DISCUS, CINHAL, SCOPUS and GOOGLE SCHOLAR, until January 15, 2020, using as search terms “Multicomponent therapies”, “Manual therapy”, “hyposteoartrithis”, “hip joint” and “therapies osteoarthritis”, for which the following Boolean connec-tors“ AND ”“ OR ”and“ NOT ”were used, of which the search algorithm is shown in Figure 1.

Inclusion criteria for the search

They included RCTs and systematic reviews that in their abstract or title presented any of the search

terms mentioned above, it is also considered or that the article was available for full-text analysis, no sample size restriction was applied in any of the articles. Exclusion criteria were letters to the editor, bibliographic reviews, and articles published in the gray literature.

Risk of bias for primary studies in reviews

The risk of bias assessment of the primary stud-ies included in the reviews included in this panoram-ic review was performed (Figure 1), for the individual bias analysis it was performed as recommended by the Cochrane Collaboration Manual (39). This tool assesses the risk of bias according to seven domains: random sequence generation, randomization sequence conceal-ment, blinding of participants and treatments, blinding of outcome evaluation, incomplete outcome data, selec-tive outcome reporting, and other biases. Each domain could be considered as low risk of bias, unclear risk of bias or high risk of bias.

RESULTS

After reviewing 30 titles and abstracts, we includ-ed 7 systematic reviews and 14 primary studies (Flow diagram). Figure 2 provides details of the clinical trials

Fig. 1. Search Flow diagram.

Record identified through database searching(Medline n66WOS n 33PEDro n 0Cinahl n 0Lilacs n 8Scielo n 0

Total = 107

Records excluded (n = 37)

Full-text articles excluded, with reasons

(n = 7)

Studies included in qualitative synthesis (n = 65)

Full-text articles assessed for eligibility (n = 72)

Iden

tific

atio

nScr

eeni

ngEl

igib

ility

Incl

uded

Additional records identified through other sources(Gray literature n = 12)

Records after duplicates removed (n = 119)

Records screened (n = 72)

EFFECTIVENESS AND CURRENT RECOMMENDATION OF MANUAL THERAPY ON HIP OSTEOARTHRITIS. AN OVERVIEW 381

used in the systematic reviews included in this pan-oramic review. Table I summarizes a series of data extracted from the systematic reviews included in this panoramic review, such as the number of included stud-ies, number of citations, and if these are cited by any review included in this panoramic review, whether or not they report at least one meta-analysis, and report risk of bias. Table II summarizes all the outcomes used by the included systematic reviews.

Risk of bias primary articles in the review

When using the Cochrane Collaboration tool to assess the risk of bias of all clinical trials, it was found that 7.69 % had a low risk of bias (36), 46.14 % had moderate risk of bias 40-43 and 46 % 14 had a high risk of bias (36,38) (Figure 3).

Effect of manual therapy on pain intensity

Seven randomized clinical trials were identified that have measured the pain intensity of hip OA by subjecting subjects to a MT intervention compared to a control group of which 4 (34,36,37,40-47) used the Visual Analog Scale, where they had to indicate their pain inten-sity in a line from 0 to 100 mm, 2 used the WOMAC index for part of the pain (36,45). The WOMAC index measures five elements for pain (score range 0-20), two for stiffness (score range 0-8) and 17 for functional lim-itation (score range 0-68), where in the pain section are

rated on a scale of 0-4, which corresponds to: None (0), Mild (1), Moderate (2), Severe (3) and Extreme, with a possible score range of 0-20 for the pain; and only the study by Paulsen et al. used the Numerical Rating Scale (NPRS) from 0 to 10 (where 0 indicates no pain and 10 indicates the worst possible pain).

In the study by Paulsen et al (37), pain intensity was measured with the NRPS, in a control group (36 individ-uals) and in a MT group (34 individuals), and as results they found that the intervention group had, on average, a score of 4 (SD: 2.5) in the NPRS in contrast to the aver-age of 4.9 (SD: 2.5) in the control group. The studies by Hoeskma et al., French et al., Bennell et al., and Black-man et al., they used the Visual Analog Scale, of which they found a greater decrease in the control groups when compared with the MT groups (Hoeskma et al. MT group: 36.7 (SD: 44), control group: 32.4 (SD: 35); French et al. MT group: 4.2 (SD: 3.42), control group: 4.02 (SD: 2.88); Bennell et al. MT group: 43.7 (SD: 24.8), control group: 39.4 (SD: 25); and Black-man et al. al. MT group: 43.8 (SD: 24.6)) (Table III). Finally, only two studies (36) used the WOMAC index of part of the pain, to assess the intensity of the pain where their results show a superior effect of the MT compared to the control group. The study by Branting-ham et al., the MT group obtained 122 (SD: 73) com-pared to the control group that obtained 136 (SD: 100) in the pain intensity evaluated by the pain part of the WOMAC index. On the other hand, the study by Abbot et al. the MT group obtained 13.7 (SD: 11.89) compared to the control group that obtained 15.52 (SD: 11.75) (Table III).

Fig. 2. Distribution of RCTs in systematic reviews.

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n G

roup

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. 39 p

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ipan

ts.

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eive

d ed

ucat

ion,

whi

ch in

clud

es t

wo

indi

vidu

al

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ions

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ee g

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sion

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up 2

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tient

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catio

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ual t

hera

py

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inim

um in

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36

part

icip

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eive

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broc

hure

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tain

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stre

tchi

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ram

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OM

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tern

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aste

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arris

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re (H

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ll ef

ficac

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rapy

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ong

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est

imat

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linic

ally s

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fican

t re

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imes

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otal

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n in

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ity: VA

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ct: 6

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nt L

iker

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vent

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: ge

nera

l med

ical

car

e gr

oup.

58 p

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ts

rece

ived

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ndar

d m

edic

al c

are

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up-2

: Com

bine

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se a

nd g

ener

al m

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n. 6

0 p

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ved

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uper

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d ex

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se t

hera

py s

essi

ons

at t

he s

tart

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e st

udy

and

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boo

ster

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e ye

ar la

ter, a

long

with

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ndar

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P c

are

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n su

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le a

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cal f

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he W

OM

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lth s

urve

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item

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36

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ct m

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n in

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ity: VA

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nctio

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ande

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al.

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4 m

onth

s6 m

onth

s10 m

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s

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up 1

: Pat

ient

edu

catio

n pl

us s

uper

vise

d ex

erci

ses.

5

5 p

artic

ipan

ts r

ecei

ved

supe

rvis

ed e

xerc

ise

and

educ

atio

n. T

he e

xerc

ise

prog

ram

con

sist

ed o

f 26 d

iffer

ent

exer

cise

s in

clud

ing

war

m-u

p, s

tren

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ning

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rcis

es,

func

tiona

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rcis

es,

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sica

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catio

n. 5

4 p

artic

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ts r

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ved

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ific

hip

OA e

duca

tion

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ary:

WOM

AC p

ain

subs

cale

inde

x w

ith V

AS

(WOM

AC p

ain)

. Sec

onda

ry: W

OM

AC s

tiffn

ess

and

phys

ical

fun

ctio

n su

bsca

les

with

VAS (W

OM

AC

stiff

ness

and

WOM

AC p

hysi

cal f

unct

ion)

, H

RQ

OL

SF-

36 v

2 a

nd t

he m

odifi

ed N

orw

egia

n ve

rsio

n of

PASE

(Con

tinue

in t

he n

ext

page

)

EFFECTIVENESS AND CURRENT RECOMMENDATION OF MANUAL THERAPY ON HIP OSTEOARTHRITIS. AN OVERVIEW 383TA

BLE

I (CO

NT.

)D

ESCR

IPTI

ON

OF

THE

CLI

NIC

AL

TRIA

LS U

SED

IN T

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MATI

C R

EVIE

WS IN

CLU

DED

IN T

HIS

OVER

VIE

W

Prim

ary

stud

ies

Subj

ects

ch

arac

terist

ics

(N°

of s

ubje

cts

incl

uded

Follo

w-u

p)

Inte

rven

tion

char

acte

rist

ics

Variab

les

Fren

ch

et a

l.

131

9 w

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18 w

eeks

Gro

up 1

: M

anua

l the

rapy

+ t

hera

peut

ic e

xerc

ises

. 43

part

icip

ants

rec

eive

d 6 t

o 8 in

dividu

al 4

5-m

inut

e ph

ysic

al

ther

apy

sess

ions

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r an

8-w

eek

period

tha

t in

clud

ed 3

0

min

utes

of TE

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f M

T

Gro

up 2

: TE

onl

y. 4

5 p

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ved

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o 8 in

dividu

al

30

-min

ute

phys

ical

the

rapy

ses

sion

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er 8

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ks,

whi

ch

incl

uded

str

engt

h an

d fle

xibi

lity

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ning

exe

rcis

es

Gro

up 3

: W

aitin

g lis

t co

ntro

l. Par

ticip

ants

in t

he c

ontr

ol

grou

p re

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ned

on t

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hysi

cal t

hera

py w

aitin

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t fo

r 9

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ks, af

ter

whi

ch t

hey

wer

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ndom

ly r

eass

igne

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TE

or T

E +

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grou

ps

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sica

l fun

ctio

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sub

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e of

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dex

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ndar

y: T

est of

bea

ring

sitt

ing.

50- F

oot to

foot

tes

tAct

ive

hip

ROM

mea

sure

d by

gon

iom

eter

NRS

SF- 3

6 Q

uest

ionn

aire

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icin

es q

uant

ifica

tion

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eOut

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nt p

hysi

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rapy

sur

vey

Ben

nell

et

al.

102

3 m

onth

s9 m

onth

s

Inde

x gr

oup:

man

ual t

hera

py (m

anip

ulat

ion,

mob

iliza

tion,

m

assa

ge a

nd s

tret

chin

g),

hom

e ex

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ses,

edu

catio

n

Con

trol

gro

up:

inac

tive

ultr

asou

nd,

inte

r ge

l with

out

mas

sage

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n in

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ity: VA

S F

unct

ion:

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AC (Li

kert

ver

sion

)Glo

bal p

erce

ived

effe

ct: 7-p

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le Q

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life:

qua

lity

of li

fe in

stru

men

t ve

rsio

n 2 A

dver

se e

vent

s

Tak

et a

l.109

8 w

eeks

3 m

onth

s

Gro

up 1

: Th

erap

eutic

Exe

rcis

es G

roup

. 55 p

artic

ipan

ts w

ho

rece

ived

a s

tren

gthe

ning

and

hea

lth p

rogr

am,

1 s

essi

on p

er

wee

k fo

r 8

wee

ks.

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engt

h tr

aini

ng w

ith g

ym e

quip

men

t w

ith

2 in

tens

ity le

vels

: lig

ht a

nd m

oder

ate;

and

a h

ome

exer

cise

pr

ogra

m

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up 2

: Con

trol

gro

up.

54 p

artic

ipan

ts r

ecei

ved

stan

dard

G

P m

edic

al c

are

VAS for

pai

nH

HS P

ain

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scal

eH

ip fun

ctio

n m

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ime

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rm

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asks

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sure

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tric

tion

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leQ

ualit

y of

life

- CV -

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S

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ott

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al.

93 h

ip O

A +

113

kne

e OA

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eeks

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ear

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up 1

: U

sual

car

e gr

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artic

ipan

ts r

ecei

ved

regu

lar

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ical

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n

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up 2

: M

T gr

oup.

54 p

artic

ipan

ts r

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ved

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al

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ions

of TM

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ent

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ing

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es

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up 3

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ts r

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ved

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al

sess

ions

of TE

tre

atm

ent

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ing

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es

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up 4

: TE

+ M

T G

roup

. 50 p

artic

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ts r

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ved

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indi

vidu

al s

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of c

ombi

ned

trea

tmen

t (T

E +

MT)

last

ing

50

min

utes

-

Fran

sen

et

al.

152

12 w

eeks

24 w

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Gro

up 1

: One

-hou

r hy

drot

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py c

lass

es,

for

12 w

eeks

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up 2

: Ta

i chi

cla

sses

for

12 w

eeks

WOM

AC:

Pai

n an

d Fu

nctio

n SF-

12

: PCS -

MCS

DASS 2

1:

Dep

ress

ion,

Anx

iety

, Str

ess

Per

form

ance

, se

cond

s: U

p an

d G

o, 5

0-fo

ot w

alk,

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ir c

limb

Bla

ckm

an

et a

l.23

6 w

eeks

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up 1

: 6

wee

ks o

f ex

erci

ses

at h

ome

Gro

up 2

: 6

wee

ks o

f ex

erci

ses

at h

ome

+ m

obiliza

tion

grad

e B

of th

e hi

p (p

assi

ve s

tret

chin

g te

chni

ques

6 w

eekl

y se

ssio

ns)

Vis

ual A

nalo

g Pai

n Sca

le, Lo

wer

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b Fu

nctio

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le,

and

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iom

etric

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sure

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d M

edia

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atio

n- :

Doe

sn’t

spec

ifies

.

384 M. ORELLANA ET AL. Rev. Soc. Esp. del Dolor, Vol. 27, N.º 6, Noviembre-Diciembre 2020

TABLE IIEXTRACT OF DATA EXTRACTED FROM SYSTEMATIC REVIEWS

Beumer / 2016

Wang / 2015

Romeo / 2013

Maly / 2014

French / 2011

Brantingham / 2009

Sampath / 2016

Cite another RS not included in matrix 1 1 No No No No Yes

Number of included studies 19 6 10 36 4 39 7

Number of studies relevant to the matrix 5 6 2 3 2 - 7

Report at least 1 meta-analysis Yes Yes No No No No Yes

Data can be reused Yes Yes No No No No Yes

Reports the risk of bias No Yes No No No No No

The risk of bias is reusable No Yes No No No No No

X: Specifies-: Doesn’t specifies.

Fig. 3. Risk of bias of studies included in the systematic reviews mentioned in Figure 2.

EFFECTIVENESS AND CURRENT RECOMMENDATION OF MANUAL THERAPY ON HIP OSTEOARTHRITIS. AN OVERVIEW 385

TABLE IIIOUTCOMES INCLUDED IN THE SYSTEMATIC REVIEWS

Outcomes Beumer / 2016

Wang / 2015

Romeo / 2013

Maly / 2014

French / 2011

Brantingham / 2009

Sampath / 2016

Pain outcome X X X X X X X

Quality of life outcome

- X X X - - X

Rom outcome - - - - - Yes Yes

Functionality outcome

- X X X X X X

Satisfaction outcome

- X - X - X -

X: Specifies-: Doesn’t specifies.

Effect of manual therapy in conjunction with exercises on pain intensity

Four randomized clinical trials were identified that have measured the pain intensity of hip OA when sub-jecting subjects to an intervention with MT + Ex in con-junction with exercises, within which 2 studies used the Visual Analog Scale (34,36,37,40,45,46) to measure the intensity of pain. The remaining 2 studies used the NPRS (37) and the WOMAC pain section (36) (Table IV). The study by French et al. obtained as results using the VAS in the MT + group Ex 42 (SD: 34.2) compared to 56.2 (SD: 28.4) in the control group; the second study using the VAS was that of Bennell et al. who obtained as results in the MT + group Ex 46.8 (SD: 26.7) and in

the control group 43.1 (SD: 27.3). On the other hand, the study by Paulsen et al. used the NRPS to assess the intensity of pain and obtained in the MT + group Ex 18 (SD: 31) compared to the control group which obtained 10 (SD: 20). And finally, the study by Abbot et al. they occupied the WOMAC index, which was obtained in the MT + group Ex 18.57 (SD: 12.56) compared to 15.52 (SD: 11.75).

Effect of manual therapy on functionality

Seven randomized clinical trials were identified that measured Functionality in subjects with hip OA when subjected to a MT intervention comparing them with

TABLE IV OUTCOME OF PAIN WITH MT INTERVENTION FROM RANDOMIZED CLINICAL TRIALS INCLUDED

IN THE REVIEWS

PainIntervention

group average

SD intervention

group

Total number of intervention

group

Control group

average

SD control group

Total number

of control group

Scales

Poulsen et al. 4 2.5 34 4.9 2.5 36 NPRS

Brantingham et al.

122 73 53 136 100 58WOMAC Pain Index

Hoeksma et al. 36.7 44 44 32.4 35 44 VAS

French et al. 4.2 3.42 43 04.02 2.88 45 VAS

Bennell et al. 43.7 24.8 39 39.4 25 44 VAS

Abbott et al. 13.7 11.89 24 15.52 11.75 23WOMAC Pain Index

Blackman et al. 43.8 24.6 11 34.55 24.6 12 VAS

NPRS: numeric pain rating scale. WOMAC Pain Index: western ontario and mcmasters osteoarthritis pain index. VAS: visual analog scale.

386 M. ORELLANA ET AL. Rev. Soc. Esp. del Dolor, Vol. 27, N.º 6, Noviembre-Diciembre 2020

a control group. The study by Paulsen et al. (37) used the Hip Disability and Osteoarthritis Scale (HOOS) con-sists of 40 items, selected from 51 original items that evaluate five separate dimensions relevant to the patient: pain (ten items); Symptoms including stiffness and range of motion (five items); Activity limitations: daily life (17 articles); Sports and recreation function (four articles); and hip-related quality of life (four items) in which a score of 80 (SD: 17) was obtained in the MT group in contrast to 69 (SD: 18) (the less, the more functionality), see Table V. The study by Hoeskma et al. he measured functionality with the Harris Hip Scoring Scale (HHS), which contains ten elements that cover four domains, which are pain, function, absence of deformity and range of motion. HHS is divided into three sections. The first section are questions about pain and its impact that are answered by the patient or client. The second and third sections require the phys-ical therapist to evaluate the hip joint and function of the patient or client. HHS is a measure of dysfunction, so the higher the score, the better the result will be for the individual. The maximum possible score is 100. The results can be interpreted with the following: <70 = poor result; 70–80 = fair, 80–90 = good, and 90–100 = excellent (47). In their study, Hoeskma et al found a score of 70.2 (SD: 20) in the MT group, and 59.7 (SD: 18) in the control group (Table V). On the other hand, the study by Blackman et al. used the Lower Limb Functional Scale (LEFS) to measure functionality in sub-jects with hip OA, which is a self-report questionnaire. Patients respond by choosing one of the 5 options for the different scenarios of the question “Today, do you have or would you have any difficulties with: 0 points = Extreme difficulty or unable to carry out activity, 1 = Fairly difficult, 2 = Moderate difficulty, 3 = A little of difficulty, 4 = No difficulty ”, and whose maximum possible score is 80 points, which indicates a very high function, and its minimum possible score is 0 points, which indicates a very low function in which, they had as results 4 (SD: 9.32) in the MT group and 6.36 (SD: 14.29) in the control group (Table V) (47). The other 4 included studies used the function section of the WOM-AC index, the study by French et al. were obtained as a result in the MT group 29.31 (SD: 17.06), and in

the control group 28.08 (SD: 15.48). In another study by Bennell et al. they obtained 27.5 (SD: 12.9) points in the MT group, and 26.4 (SD: 11.3) in the control group. In the study by Abbott et al. 52.25 (SD: 41.12) points were obtained in the MT group, and in the con-trol group they found 63.74 (SD: 45.22). Finally, the study by Brantingham et al. 740 (SD: 561) points were obtained in the MT group, and 619 (SD: 405) points in the WOMAC index (46) (Table V).

Effect of manual therapy in conjunction with exercises on functionality

Regarding the effects of MT + Ex on functionality, we found 2 randomized clinical trials included in the reviews reviewed in this study (34,36). The study by French et al. used the functionality section of the WOMAC index, in which they obtained 29.31 (SD: 17.06) points in the MT + Ex group, and in the control group 36.09 (SD: 16.41) points. And in the study by Abbott et al. using the same functionality section of the WOMAC index, in which it obtained in the MT + group Ex 67.9 (SD: 46.13) points, compared to 63.73 (SD: 45.21) points in the control group (Table VI).

Analysis of results through Forest Plot

The results included in the reviews of this study in order to qualify for meta-analysis of each of the system-atic reviews, were grouped into different outcomes for the analysis through the forest plot, which shows us whether they are statistically significant for the inter-vention group or towards the control group, the first analysis focused on quality of life for patients with OA, the results reported by this statistical analysis favored the intervention group with manual therapy overall, but these were not statistically significant towards said group (Figure 4). The second analysis was carried out to measure the decrease in pain with MT, the results presented by the forest plot analysis for this outcome, show that the overall changes favored the control group, but the results were not statistically significant

TABLE VFUNCTIONALITY OUTCOME WITH MT INTERVENTION OF THE RANDOMIZED CLINICAL TRIALS

INCLUDED IN THE REVIEWS

PainIntervention

group average

SD intervention

group

Total number of intervention

group

Control group

average

SD control group

Total number of control

groupScales

Poulsen et al. (-)18 31 34 (-)10 20 32 NPRS

French et al. 42 34.2 43 56.2 28.4 43 VAS

Bennell et al. 46.8 26.7 39 43.1 27.3 44 VAS

Abbott et al. 18.57 12.56 21 15.52 11.75 23WOMAC

Pain

NPRS: numeric pain rating scale. WOMAC Pain Index: western ontario and mcmasters osteoarthritis pain index. VAS: visual analog scale.

EFFECTIVENESS AND CURRENT RECOMMENDATION OF MANUAL THERAPY ON HIP OSTEOARTHRITIS. AN OVERVIEW 387

TABLE VIOUTCOME OF FUNCTIONALITY WITH MT INTERVENTION OF THE RANDOMIZED CLINICAL TRIALS INCLUDED

IN THE REVIEWS

FunctionalityIntervention

group average

SD intervention

group

Total number of intervention

group

Control group

average

SD control group

Total number

of control group

Scales

Poulsen et al. (-)80 17 34 (-)69 18 36 HOOS Function

Brantingham et al.

740 561 53 619 405 58WOMAC Function

French et al. 29.31 17.06 43 28.08 15.48 45WOMAC Function

Bennell et al. 27.5 12.9 49 26.4 11.3 53WOMAC Function

Abbott et al. 52.25 41.12 24 63.74 45.22 23WOMAC Function

Hoeksma et al. 70.2 20 44 59.7 18 44 HHS

Blackman et al. 4.00 9.32 10 6.36 14.29 11 LEFS

HOOS: hip osteoarthritis disability and osteoarthritis outcome score. WOMAC Function Index: western ontario and mcmasters osteoarthritis function index. HHS: harris hip score. LEFS: limb functional scale.

Experimental Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random,

95 % CI IV, Random, 95 % CI

Bennell KL 2014 0.68 0.19 39 0.74 0.17 44 100.0 % -0.06 [-0.14, 0.02]

French HP 2013 -35.61 11.22 43 -33.82 9.67 43 0.0 % -1.79 [-6.22, 2.64]

Total (95 % CI) 82 87 100.0 % -0.06 [-0.14, 0.02]

Heterogenelty: Tau2 = 0.00; Chi2 = 0.59, df = 1 (P = 0.44); I2 = 0 %Test for overall effect: Z = 1.52 (P = 0.13)

-1 1-0.5 0.50Favours [experimental] Favours [control]

Fig. 4. Forest plot of functional changes in hip osteoarthritis.

in favor of the group of intervention with MT (Figure 5). The third analysis measured the functionality, unlike the previously exposed outcomes, the functionality outcome did not present an overall change towards either of the two groups, showing no statistically significant differenc-es for any of the previously exposed groups (Figure 6). For the overall perception of MT by the patients included in the studies, they did not have a clear preference neither in favor of the experimental group nor towards the control group (Figure 7). Finally, the analysis of adverse effects with the interventions had an overall effect towards the control group, but this change or inclination was not statistically significant.

Clinical and statistical heterogeneity

Our review describes different parameters and results in the data evaluation, which generated marked statistical heterogeneity, which is attributed to the fact that not all systematic reviews presented significantly statistical data in their results, the above was present-ed for the intervention group and for the control group. This did not allow any of the systematic reviews to be meta-analyzed, leaving enough questions to determine the correct effect of the manual therapy intervention in hip OA. From the point of view of clinical heterogeneity, this was to a lesser extent since the majority of the

388 M. ORELLANA ET AL. Rev. Soc. Esp. del Dolor, Vol. 27, N.º 6, Noviembre-Diciembre 2020

Experimental Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random,

95 % CI IV, Random, 95 % CI

Abbott JH 2013 13.7 11.89 24 15.52 11.75 23 1.6 % -1.82 [-8.58, 4.94]

Bennell KL 2014 43.7 24.8 39 39.4 25 44 0.6 % 4.30 [-6.43, 15.03]

Blackman F 2014 43.8 24.6 11 34.55 24.6 12 0.2 % 9.25 [-10.88, 29.38]

Brantingham JW 2012 122 73 53 136 100 58 0.1 % -14.00

[-46.38, 18.38]

French HP 2013 4.2 3.42 43 4.02 2.88 45 42.7 % 0.18 [-1.14, 1.50]

Hoelcsma HL 2004 36.7 44 44 32.4 35 44 0.3 % 4.30

[-12.31, 20.91]

Poulsen E 2013 4 2.5 34 4.9 2.5 36 54.5 % -0.90 [-2.07, 0.27]

Total (95% CI) 248 262 100.0 % -0.40 [-1.26, 0.47]

Heterogenelty: Tau2 = 0.00; Chi2 = 4.21, df = 6 (P = 0.65); I2 = 0 %Test for overall effect: Z = 0.90 (P = 0.37)

-4 4-2 20Favours [experimental] Favours [control]

Fig. 5. Forest plot of functional changes in hip osteoarthritis.

Experimental Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random,

95 % CI IV, Random, 95 % CI

Abbott JH 2013 52.25 41.12 24 63.74 45.22 23 4.8 % -11.49 [-36.23, 13.25]

Bennell KL 2014 27.5 12.9 49 26.4 11.3 53 23.3 1.10 [-3.62, 5.82]

Blackman F 2014 4 9.32 10 6.36 14.29 11 15.2 % -2.36 [-12.59, 7.87]

Brantingham JW 2012 740 561 53 619 405 58 0,1% 121.00

[-62.51, 304.51]

French HP 2013 29.31 17.06 43 28.08 15.48 45 20.1 % 1.23 [-5.59, 8.05]

Hoelcsma HL 2004 70.2 20 44 59.7 18 44 18.4 % 10.50

[2.55, 18.45]

Poulsen E 2013 -80 17 34 -69 18 36 18.0 % -11.00 [-19.20, -2.80]

Total (95% CI) 257 270 100.0 % -0.33 [-16.33, 5.66]

Heterogenelty: Tau2 = 34.38; Chi2 = 16.59, df = 6 (P = 0.01); I2 = 64 %Test for overall effect: Z = 0.11 (P = 0.91)

-20 20-10 100Favours [experimental] Favours [control]

Fig. 6. Forest plot evaluating outcome of functionality with MT in hip osteoarthritis.

EFFECTIVENESS AND CURRENT RECOMMENDATION OF MANUAL THERAPY ON HIP OSTEOARTHRITIS. AN OVERVIEW 389

Experimental Control Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95 % CI M-H, Random, 95 % CI

Bennell KL 2014 22 49 26 53 24.5 % 0.92 [0.60, 1.38]

Blackman F 2014 42 53 52 58 29.5 % 0.88 [0.75, 1.04]

Hoelcsma HL 2004 43 56 28 53 27.3 % 1.45 [1.09, 1.95]

Poulsen E 2013 26 43 8 39 18.7 % 2.95 [1.52, 5.72]

Total (95% CI) 201 203 100.0 % 1.28 [0.81, 2.02]

Total events 133 114

Heterogenelty: Tau2 = 0.18; Chi2 = 23.41, df = 3 (P = 0.0001); I2 = 87 %Test for overall effect: Z = 1.05 (P = 0.29)

0.01 1000.1 101Favours [experimental] Favours [control]

Fig. 7. Forest plot that evaluates global perception outcome of MT in hip osteoarthritis.

RCTs included in the systematic reviews analyzed similar clinical outcomes, the interventions were quite homoge-neous, the patients did not show marked differences, and the groups of intervention as control groups were quite homogeneous, this can be attributed to the fact that the reviews included in this study presented similar primary studies among them.

DISCUSSION

This panoramic literature review provides an over-view of the systematic reviews included in the liter-ature on the scientific evidence for the conservative management of hip osteoarthritis, the studies ana-lyzed (32-35,46,48,49) reported in favor of manual therapy, but due to the lack of statistical power of the results, these cannot be categorical as the standard conservative intervention in the management of hip OA. Osteoarthritis of the hip is a complex condition that often requires surgical management, which is always a complex conditioner for patients and for the manage-ment of the deleterious condition to any type of surgery (43,50). Therapeutic exercise in the most common hip OA of physical therapy and manual therapy (49). For this intervention, the results of our panoramic review evaluated a varied number of outcomes that are part of a global therapeutic evaluation or the Gold standard for this type of patients, although what was expected was to be able to find some absolute guidelines for therapeutic management, the statistical heterogeneity presented suggests that manual therapy is a useful complement, but not absolutism, for the conservative management of this type of patient. If we analyze in detail because the studies show some differences, it is because a high number of the RCTs included in the systemic reviews had a high and medium level of bias, which could also mean that these data cannot be so reliable, therefore, they cannot be interpreted in the same way. The only RTCs included in the systematic reviews was that of Abbott JH, et al, which presented only one level of the scale of bias poor, when comparing the results with the other RCTs, we can interpret that their results based on the outcomes described, if they

were in favor of manual therapy, but compared to the control group, these were not statistically significant like the other RCTs (36). To our knowledge, this is the first panoramic review comparing the effect of manual therapy on hip osteoarthritis, therefore we propose to carry out new primary studies to eliminate some biases in program execution and improve intervention in the control group, such as in the intervention group.

Finally, it is necessary to mention the limitations of our study are as follows: although we searched six data-bases and included articles in 2 languages, we could have lost relevant articles for our search; there was a high degree of statistical heterogeneity among the stud-ies including the possible sources of heterogeneity could be variations in the type and dose of the interventions used, and the results measured; methodological limita-tions such as the lack of an adequate sample size, the unclear randomization, improperly concealed allocation, and lack of blinding of assessors could overestimate the effect size of the interventions studied; due to the lim-ited number of included studies, publication bias could not be assessed.

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